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DOI: 10.1016/j.ijep.2014.11.002
Knowledge, attitude and practice of parents regarding pediatric antiepileptic drug therapy
Publikationsverlauf
Received: 30. April 2014
Accepted: 11. November 2014
Publikationsdatum:
04. Mai 2018 (online)
Abstract
Objectives To evaluate the parental knowledge, attitude and practice (KAP) regarding the antiepileptic medication therapy in childhood.
Methods This study was carried out over a period of 10 months in the division of Pediatric Neurology of Amrita Institute of Medical Sciences. The cohort of patients was selected randomly meeting the inclusion and exclusion criteria. Parents' KAP regarding epilepsy and antiepileptic drug therapy was assessed using a questionnaire prepared by the authors and patient adherence towards antiepileptic drug therapy by using Pediatric Epilepsy Self-Management Questionnaire (PEMSQ).
Results A total of 123 patients were selected and enrolled in the study. Seventy eight percent of the respondents knew that epilepsy is a brain disorder, while only 6% of them were aware about all the treatment options. The scoring in the domain of “Disease and Treatment Knowledge & Expectations of parents” was found to be significantly low (69.07%) when compared to other domains in the PEMSQ. Although socioeconomic status did not correlate with knowledge score of the parents (p = 0.216), it was significantly related to adherence (p = 0.042).
Conclusion In this cohort, even though the parents had a fair knowledge about the nature of epilepsy, they were found to be less aware about its characteristics, causes and prognosis. The awareness about the nature and duration of treatment, its objectives, use of drugs, their side effects and importance of adherence to drug regimen was found to be significantly low with a potential for affecting the therapeutic outcome. Special awareness programs for parents of children with epilepsy may be needed to reduce the knowledge gaps in the management of epilepsy and to ensure compliance and optimal therapeutic outcomes.
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Epilepsy is a chronic medical condition, which requires long term management. Adherence to antiepileptic drugs (AEDs) is crucial for preventing the risk of recurrent seizures. Knowledge about the disease condition and medications can influence the compliance towards antiepileptic drug therapy.[1] [2] Recently conducted knowledge, attitude and practice (KAP) studies from developed countries had shown an emergence of a positive attitude toward epilepsy.[3] [4] [5] However, epilepsy still continues to be a highly stigmatizing disease in most developing countries.[6] [7] [8] Prior evidence showed that parents have inadequate knowledge regarding disease and pharmacotherapy of their children with epilepsy.[9] [10] Lack of knowledge and inappropriate beliefs are the major obstacles to successful epilepsy management. Quality of life will be significantly affected by non adherence to AEDs due to the occurrence of frequent breakthrough seizures and also by increased hospital admissions. It may also lead to serious consequences like status epilepticus and sudden unexpected death in epilepsy (SUDEP).[11] [12] [13]
The medication management of pediatric patients with epilepsy largely depends on the attitudes of their parents and caregivers.[14] Good drug compliance can be achieved by imparting health education to both patient and family.[15] Counseling and communication between health professionals and parents of children with epilepsy regarding nature of disease, its characteristics, medications used, benefits of AEDs, dosage adjustments, potential drug interactions, adverse effects and need for adherence to therapy is essential.[16]
In the current study, an attempt has been made to assess Knowledge, Attitude and Practice (KAP) of the parents regarding epilepsy and antiepileptic medication therapy and also patient adherence towards antiepileptic drug therapy using Pediatric epilepsy medication Self-Management Questionnaire (PEMSQ).
1Methods
This study was carried out for a period of 10 months between 1st September 2012 to 30th June 2013 in the Epilepsy clinic of the Division of Pediatric Neurology, Department of Neurology of Amrita Institute of Medical Sciences, Kochi, Kerala, India. The hospital Research and Ethics Committee scrutinized the protocol and gave ethical approval for the study. An information leaflet describing the study pattern was given to the parents and informed consent was obtained from respondents prior to the commencement of interviews.
Patients who satisfied the inclusion and exclusion criteria were selected randomly and enrolled in the study. We included children with epilepsy aged <18 years, who were on long term AEDs, and with regular follow up visits accompanied by parents who were able to read and speak English or the local language Malayalam. We excluded parents who were not willing to participate in the study or not ready to give an informed consent. A standardized data collection form prepared by the investigators was used to obtain necessary data from the parents who were then assessed for their KAP and adherence to medications.
Two questionnaires were administered to the parents: KAP questionnaire and PEMSQ. KAP questionnaire prepared by the first author with 34 questions designed in English and local language Malayalam was used to assess KAP of the parents regarding pediatric antiepileptic drug therapy. It included questions that dealt with the disease condition, symptoms, management of seizures, different treatment options for epilepsy, proper use and storage of medications, beliefs about medication efficacy, need for adherence to AED therapy and its side effects. The initial 10 questions were related to general awareness about epilepsy and the remaining 24 questions about the general practice and knowledge of epilepsy treatment. The questionnaire was reviewed in detail by the second author, and two other senior neurologists with vast clinical and research experience in epilepsy for the clinical appropriateness of the questions and modifications were made according to their suggestions. Then a pilot study was conducted on the proposed study population to decide on the reliability and the clinical applicability of the questionnaire. It was planned to view the responses qualitatively. However, an arbitrary scoring was also given as +1 and −1depending on the perceived impact of the responses in the overall quality of life of children with epilepsy.
The second questionnaire used, the PEMSQ is one of the initial scales used in assessing aspects that are salient to a pediatric epilepsy population.[17] It is a 27 item measure consisting of four sections: Epilepsy and Treatment Knowledge and Expectations, Adherence to Medications and Clinic Appointments, Beliefs about Medication Efficacy and Barriers to Medication Adherence. It evaluates caregivers' perceptions of their understanding of epilepsy, antiepileptic drug therapy and its management, adhering to the prescribed treatment regimen, how well they believe the medication will work to treat seizures and barriers that make it difficult for their child to take medications as prescribed. Two response sets were used on the questionnaire: “Strongly disagree” to “Strongly agree” or “never” to “always”. These scales together make up a total self-management score ranging from 27 to 135 which refers to all the activities required to control seizures and to reduce side effects, including taking AEDs, engaging in healthy lifestyle behaviors, active participation in decision making with the healthcare team and managing stress. Higher scores represent better self-management.
All the data were tabulated, analyzed and compared with data from other studies. The collected data were compiled using Microsoft excel. Statistical analysis was performed using SPSS Version 20. The significance of the study results were assessed using Fisher's exact test, paired sample t-test, analysis of variance (ANOVA) and correlation analysis.
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Results
A total of 123 children were recruited for the study, which included 62 males and 61 females. Their mean age was 4.74 ± 4.38 years. The demographic data of the patients are shown in [Table 1].
Twenty-eight children (22.76%) depended previously on various alternative systems of medicines. Among them, 23 (18.69%) used ayurveda, 2 (1.63%) were on homeopathy and acupuncture respectively, and one person used Unani system (0.81%). The remaining 95 (77.24%) children solely used AEDs as polytherapy or monotherapy in which polytherapy dominated over monotherapy. Out of the 123 children, 26 (21.14%) were on ketogenic diet while the rest 97 children were managed with AEDs (78.86%). The various drugs prescribed in this study population are illustrated in [Table 1].
Majority of the parents were found to be less knowledgeable about the nature of epilepsy, its characteristics, causes and prognosis, nature and duration of treatment, its objectives, proper use and storage of drugs, their side effects and importance of adherence to drug regimen. The mean KAP score of the respondents was found to be 19.58 ± 3.78 (−34 to +34). About 97 (79%) of the parents knew that epilepsy is a brain disorder and 2 (1.16%) believed that it is always hereditary. Nearly 112 (91%) of them were aware that symptoms and severity of epileptic attacks vary from patient to patient. According to 68 (55%) respondents, febrile seizures could not be labeled as epilepsy. Only 7 (6%) parents were aware of all the treatment options other than AEDs.29 (24%) of them believed that ketogenic diet has a role in controlling seizure attacks.35 respondents (28%)were aware that blood samples can be used to measure the concentration of AEDs in the body. Almost 122 (99%) knew correctly about the proper use and storage of drugs. Among 123 participants, 16 (13%) did not know that a complete seizure free period is absolutely essential for stopping AEDs. Six (4.8%) of them believed that AEDs are addictives and therefore it would be difficult to stop taking it at a later date. Seventy-three (59%) parents thought that some AEDs can affect memory and concentration of the child, even though 26 (21%) of them reported that AED therapy won't have any side effects. The parental response to each of the KAP questionnaire is listed in [Table 2].
Among the total 123 responses in PEMSQ, 9 (7.32%) parents had some basic knowledge about the treatment related side effects whereas 114 parents (92.68%) were not aware of any adverse effects of AEDs. About 104 (84.55%) were confident enough to manage side effects if they occur, in partnership with the health care team whereas 19 of them (15.45%) were not. Ninety-nine of them (80.49%) were conscious about the risks of discontinuing their child's medication before he/she has been seizure free for a minimum period of two years while 24 (19.51%) were unaware of that. Over 121 of the participants (98.37%) informed that they usually followed the medical advice and treatment plans prescribed for their children.122 parents (99.19%) felt it is important for their child to receive his/her treatment as directed and 121 of them (98.37%) stressed the importance to assure that their child takes his/her medication on a daily basis. 120 parents (98%) believed that medication treatment is necessary for their child's epilepsy whereas 20 (16%) said that the medication chosen had not controlled their child's seizures. Medications are easy to fit into the daily schedule of 120children (98%). Sixty-six of them (54%) said that their child often dislikes the taste of the medication, 75 (61%) mentioned that the medication is difficult for the child to swallow and 81 of them (66%) reported that the child sometimes refused to take his/her medication. Nearly six of the respondents (5%) had run out of their AEDs occasionally and 20 (16%) often found difficulty in getting their medication from the pharmacy. [Table 3] denotes the details of PEMSQ scoring of the respondents in different subsections.
Most of the participants identified medication related factors as the major reason for non adherence to AEDs. The primary reason for non adherence mentioned by 105 (85.36%) respondents was fear of side effects. While 34 (27.64%) parents found it difficult due to polypharmacy, other reasons reported were increased frequency of dosing by 23 (18.6%), cost of medications by 22 (17.89%) and prolonged duration of therapy by 17 (13.82%) parents. Ten (8.13%) and 12 (9.76%) of them ranked patient related factors like forgetfulness and travel respectively as other reasons for non adherence to antiepileptic drug therapy.
A statistically significant association was observed between socioeconomic status of the parents and adherence score (p = 0.042). No significant relationship was found between socioeconomic status of the parents and their knowledge score (p = 0.216).
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Discussion
We investigated the Knowledge, Attitude and Practice (KAP) of parents regarding the antiepileptic drug therapy of their children with epilepsy in a tertiary care hospital setting. Most of our patients were on polytherapy and some were on ketogenic diet which suggests that the study population included a significantly high proportion of children with refractory epileptic syndromes with relatively high seizure burden. So the findings of this study may not be directly applicable to the general population. However even in such a cohort, we found clear knowledge gaps, mainly concerning medications and therapy of epilepsy. It was found that even though the parents of children with epilepsy were knowledgeable regarding the nature of epilepsy, its characteristics, causes, and prognosis, they were less aware about the nature of treatment, its objectives, use of drugs, importance of adherence to the drug regimen, potential side effects and interactions of drugs, and duration of treatment. They were concerned about the seizures and their effect on various aspects of the lives of children, and also about long term side effects of AEDs.
According to existing literature awareness about epilepsy is generally poor,[18] [19] [20] [21] particularly with regard to certain aspects of epilepsy[18] [22] [23] like etiology, use and administration of AEDs,[24] and emergency management of seizures.[25] The findings of our study is at variance with a Sudanese KAP study in which only 30% of the respondents knew epilepsy as a brain disorder.[26] An earlier population based KAP study from Kerala in which 27% of participants reported epilepsy as supernatural.[27] In this group, only 4parents considered a supernatural causation for epilepsy. The difference in the study setting might be the primary reason for this discordance. This study concurs with the studies from Sudan[28] and Brazil[29] reporting that the awareness of epilepsy as a curable disease by a majority of respondents. It was encouraging to note that unlike some other populations,[26] [27] [30] none of our respondents considered epilepsy being contagious. The study by Joshi et al[31] in which 77% of the study population thought that epilepsy needed lifelong treatment correlates with our findings.
Medication adherence in epilepsy is mainly related to the knowledge regarding the importance of regular drug intake. However, Dawkins et al[21] reported that many patients were worried about the side effects of medications and risk of drug dependence. In our study group also, many parents were worried about the effects of long term administration of drugs and the chance of drug dependence. Another KAP survey from rural Gujarat demonstrated the lack of awareness about the proper usage of drugs, storage of medicine and their expiry dates.[32] This low level of knowledge was consistent with the findings of many other studies.[33] [34] Our results showing the inadequate knowledge of parents about AEDs and their side effects did not support the study from Turkey[35] and Nigeria[36] in which the parents of children with epilepsy of 8–17 years of age who knew about epilepsy were found to be more aware about AEDs used and their side effects. Hirfanoglu et al[35] reported that both maternal education and employment were correlated with better knowledge of epilepsy (p = 0.004). However, there was no correlation between the knowledge about epilepsy and AEDs and educational qualifications (p = 0.216). The difference in the characteristics of the study population may explain these variations.
Several studies have shown that parents with low family income were more likely to have less knowledge about epilepsy and its treatment.[35] [37] Our study underlines that adherence pattern is significantly associated with socioeconomic status (p = 0.042) which is identical to previous studies.[38] [39] [40] Lower socioeconomic status of parents was usually associated with higher non adherence (p < 0.001). Previous studies suggested that adherence to medications among patients with epilepsy is sub-optimal.[41] [42] In spite of better knowledge, high costs of medication and forgetfulness were the most frequent reasons given for poor compliance.[43] [44] Our study also shows the same pattern. A similar trend was observed in a study from New York,[45] which also revealed that forgetfulness was the most often cited reason for noncompliance.
This study showed that a significant proportion of parents of children with epilepsy are unaware about the implications of antiepileptic drug therapy of their children. Improving the understanding about epilepsy and its management along with the overall medical care may ultimately enhance adherence, which will help to improve the therapeutic outcomes and overall quality of life in children with epilepsy. The present study also highlights a significant impact of low socioeconomic status on drug compliance, suggesting the necessity of improved social support in such population. There is also a need for improving the parental awareness as they play a pivotal role in the management of children with epilepsy. Educational efforts directed at parents may have a significant beneficial effect on the well being of children with epilepsy by ensuring optimal therapeutic outcome.
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Conflicts of interest
All authors have none to declare.
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Die Autoren geben an, dass kein Interessenkonflikt besteht.
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References
- 1 Garnett WR. Antiepileptic drug treatment: outcomes and adherence. Pharmacotherapy 20 2000; 191-199
- 2 Lewis CC, Scott DE, Pantell RH, Wolf MH. Parent satisfaction with children's medical care: development, field test, and validation of a questionnaire. Med Care 24 1986; 209-215
- 3 Canger R, Cornaggia C. Public attitudes toward epilepsy in Italy: results of a survey and comparison with U.S.A. and West German data. Epilepsia 26 1985; 221-226
- 4 Caveness WF, Gallup Jr GH. A survey of public attitudes toward epilepsy in 1979 with an indication of trends over the past thirty years. Epilepsia 21 1880; 509-518
- 5 Jensen R, Dam M. Public attitudes toward epilepsy in Denmark. Epilepsia 33 1992; 459-463
- 6 Gambhir SK, Kumar V, Singhi PD, Goel RC. Public awareness, understanding and attitudes toward epilepsy. Indian J Med Res 102 1995; 34-38
- 7 Lai CW, Huang X, Lai YH, Zhang Z, Liu G, Yang MZ. Survey of public awareness, understanding, and attitude toward epilepsy in Henan Province, China. Epilepsia 31 1990; 182-187
- 8 Rwiza HT, Matuja WB, Kilonzo GP. et al. Knowledge, attitude and practice toward epilepsy among rural Tanzanian residents. Epilepsia 34 1993; 1017-1023
- 9 McNelis AM, Buelow J, Myers J, Johnson EA. Concerns and needs of children with epilepsy and their parents. Clin Nurse Spec 21 2007; 195-202
- 10 Shore C, Austin J, Musick B, Dunn D, McBride A, Creasy K. Psychosocial care needs of parents of children with new-onset seizures. J Neurosci Nurs 30 1998; 169-174
- 11 Baker GA, Jacoby A, Buck D, Stalgis C, Monnet D. Quality of life of people with epilepsy: a European study. Epilepsia 38 1997; 353-362
- 12 Koshy S. Role of pharmacists in the management of patients with epilepsy. Int J Pharm Pract 20 2012; 65-68
- 13 Thomas SV, Koshy S, Nair CR, Sarma SP. Frequent seizures and polytherapy can impair quality of life in persons with epilepsy. Neurol India 53 2005; 46-50
- 14 Chen C, Lee DS, Hie SL. The impact of pharmacist's counseling on pediatric patients' caregiver's knowledge on epilepsy and its treatment in a tertiary hospital. Int J Clin Pharm 35 2013; 829-834
- 15 Sureka RK, Sureka R. Knowledge, attitude and practices with regard to epilepsy in rural north-west India. Ann Indian Acad Neurol 10 2007; 160-164
- 16 Walker MP, McGovern TL, Hattingh LH, Hall TD. Medication management of adult patients admitted to hospital with epilepsy, seizure or convulsion. J Pharm Pract Res 42 2012; 291-295
- 17 Modi AC, Monahan S, Danniels D, Glauser TA. Development and validation of the pediatric epilepsy medication self-management questionnaire. Epilepsy Behav 18 2010; 44-99
- 18 Hawley SR, Paschal AM, Ablah E. et al. Initial perspectives from Midwestern neurologists: epilepsy patients' barriers and motivators for seeking treatment. Epilepsia 48 2007; 1920-1925
- 19 Huberty TJ, Austin JK, Harezlak J, Dunn DW, Ambrosius WT. Informant agreement in behavior ratings for children with epilepsy. Epilepsy Behav 1 2000; 427-435
- 20 Long L, Reeves AL, Moore JL, Roach J, Pickering CT. An assessment of epilepsy patients' knowledge of their disorder. Epilepsia 41 2000; 727-731
- 21 Dawkins JL, Crawford PM, Stammers TG. Epilepsy: a general practice study of knowledge and attitudes among sufferers and non-sufferers. Br J Gen Pract 43 1993; 453-457
- 22 Ried S, Specht U, Thorbecke R, Goecke K, Wohlfarth R. MOSES: an educational program for patients with epilepsy and their relatives. Epilepsia 3 2001; 76-80
- 23 Tran DS, Odermatt P, Singphuoangphet S. et al. Epilepsy in Laos: knowledge, attitudes, and practices in the community. Epilepsy Behav 10 2007; 565-570
- 24 Jarvie S, Espie CA, Brodie MJ. The development of a questionnaire to assess knowledge of epilepsy: general knowledge of epilepsy. Seizure 2 1993; 179-185
- 25 Goldstein LH, Minchin L, Stubbs P, Fenwick PB. Are what people know about their epilepsy and what they want from an epilepsy service related?. Seizure 6 1997; 435-442
- 26 Sidig A, Ibrahim G, Hussein A. et al. A study of knowledge, attitude, practice towards epilepsy among relative of epileptic patients in Khartoum State. Sudan J Public Health 4 2009; 393-398
- 27 Radhakrishnan K, Pandian JD, Santhoshkumar T. et al. Prevalence, knowledge, attitude, and practice of epilepsy in Kerala, south India. Epilepsia 41 2000; 1027-1035
- 28 Babikar HE, Abbas IM. Knowledge, practice and attitude toward epilepsy among primary and secondary school teachers in south Gezira locality, Gezira State, Sudan. J Family Community Med 18 2011; 17-21
- 29 Noronha AL, Andrade MG, Fernandes PT, Santiago SM, Sander SW. Training medical students to improve the management of people with epilepsy. Arq Neuropsiquiatr 65 2007; 23-27
- 30 Gedefa M, Wolde T, Solomon G. Knowledge, attitudes and practices with respect to epilepsy among Preparatory School Students in Mekelle city, Ethiopia. Int J Collab Res Intern Med Public Health 4 2012; 203-215
- 31 Joshi HS, Mahmood SE, Bamel A, Agarwal AK, Shaifali I. Perception of epilepsy among the urban secondary school children of Bareilly district. Ann Indian Acad Neurol 15 2012; 125-127
- 32 Shah AP, Parmar SA, Ramkishan A, Mehta AA. Knowledge, attitude and practice (KAP) survey regarding the safe use of medicines in rural area of Gujarat. Adv Trop Med Pub Health Int 1 2011; 66-70
- 33 McCluggage J, Ramsey HC, Irwin WG, Dowds MF. Anticonvulsant therapy in a general practice in Northern Ireland. J R Coll Gen Pract 34 1984; 24-31
- 34 Dowds N, McCluggage J, Nelson J. A Survey of the Socio-medical Aspects of Epilepsy in a General Practice Population in Northern Ireland. 1983. British Epilepsy Association Publications; London:
- 35 Hirfanoglu T, Serdaroglu A, Cansu A, Soysal S, Derle E, Gucuyener K. Do knowledge of, perception of, and attitudes toward epilepsy affect the quality of life of Turkish children with epilepsy and their parents?. Epilepsy Behav 14 2009; 71-77
- 36 Frank-Briggs AI, Alikor EA. Knowledge and attitudes of parents towards children with epilepsy. Ann Afr Med 10 2011; 238-242
- 37 Deng CT, Med M, Zulkifli HI, Azizi BHO. Parental reactions to febrile seizures in Malaysian children. Med J Malaysia 51 1994; 462-468
- 38 Modi AC, Rausch JR, Glauser TA. Patterns of nonadherence to antiepileptic drug therapy in children with newly diagnosed epilepsy. JAMA 305 2011; 1669-1676
- 39 Bobrow ES, AvRuskin TW, Siller J. Mother-daughter interaction and adherence to diabetes regimens. Diabetes Care 8 1985; 146-151
- 40 Patterson Jm. Critical factors affecting family compliance with home treatment for children with cystic fibrosis. Fam Relat 34 1985; 79-89
- 41 Davis KL, Candrilli SD, Edin HM. Prevalence and cost of non adherence with antiepileptic drugs in an adult managed care population. Epilepsia 49 2008; 446-454
- 42 Ettinger AB, Baker GA. Best clinical and research practice in epilepsy of older people: focus on antiepileptic drug adherence. Epilepsy Behav 15 2009; 60-63
- 43 Eisler J, Mattson RH. Compliance in anticonvulsant drug therapy. Epilepsia 16 1975; 203-206
- 44 Faught E, Duh MS, Weiner JR, Guerin A, Cunnington MC. Nonadherence to antiepileptic drugs and increased mortality: findings from the ransom study. Neurology 71 2008; 1572-1578
- 45 Nakhutina L, Gonzalez JS, Margolis SA, Spada A, Grant A. Adherence to antiepileptic drugs and beliefs about medication among predominantly ethnic minority patients with epilepsy. Epilepsy Behav 22 2011; 584-586
*
Corresponding author
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References
- 1 Garnett WR. Antiepileptic drug treatment: outcomes and adherence. Pharmacotherapy 20 2000; 191-199
- 2 Lewis CC, Scott DE, Pantell RH, Wolf MH. Parent satisfaction with children's medical care: development, field test, and validation of a questionnaire. Med Care 24 1986; 209-215
- 3 Canger R, Cornaggia C. Public attitudes toward epilepsy in Italy: results of a survey and comparison with U.S.A. and West German data. Epilepsia 26 1985; 221-226
- 4 Caveness WF, Gallup Jr GH. A survey of public attitudes toward epilepsy in 1979 with an indication of trends over the past thirty years. Epilepsia 21 1880; 509-518
- 5 Jensen R, Dam M. Public attitudes toward epilepsy in Denmark. Epilepsia 33 1992; 459-463
- 6 Gambhir SK, Kumar V, Singhi PD, Goel RC. Public awareness, understanding and attitudes toward epilepsy. Indian J Med Res 102 1995; 34-38
- 7 Lai CW, Huang X, Lai YH, Zhang Z, Liu G, Yang MZ. Survey of public awareness, understanding, and attitude toward epilepsy in Henan Province, China. Epilepsia 31 1990; 182-187
- 8 Rwiza HT, Matuja WB, Kilonzo GP. et al. Knowledge, attitude and practice toward epilepsy among rural Tanzanian residents. Epilepsia 34 1993; 1017-1023
- 9 McNelis AM, Buelow J, Myers J, Johnson EA. Concerns and needs of children with epilepsy and their parents. Clin Nurse Spec 21 2007; 195-202
- 10 Shore C, Austin J, Musick B, Dunn D, McBride A, Creasy K. Psychosocial care needs of parents of children with new-onset seizures. J Neurosci Nurs 30 1998; 169-174
- 11 Baker GA, Jacoby A, Buck D, Stalgis C, Monnet D. Quality of life of people with epilepsy: a European study. Epilepsia 38 1997; 353-362
- 12 Koshy S. Role of pharmacists in the management of patients with epilepsy. Int J Pharm Pract 20 2012; 65-68
- 13 Thomas SV, Koshy S, Nair CR, Sarma SP. Frequent seizures and polytherapy can impair quality of life in persons with epilepsy. Neurol India 53 2005; 46-50
- 14 Chen C, Lee DS, Hie SL. The impact of pharmacist's counseling on pediatric patients' caregiver's knowledge on epilepsy and its treatment in a tertiary hospital. Int J Clin Pharm 35 2013; 829-834
- 15 Sureka RK, Sureka R. Knowledge, attitude and practices with regard to epilepsy in rural north-west India. Ann Indian Acad Neurol 10 2007; 160-164
- 16 Walker MP, McGovern TL, Hattingh LH, Hall TD. Medication management of adult patients admitted to hospital with epilepsy, seizure or convulsion. J Pharm Pract Res 42 2012; 291-295
- 17 Modi AC, Monahan S, Danniels D, Glauser TA. Development and validation of the pediatric epilepsy medication self-management questionnaire. Epilepsy Behav 18 2010; 44-99
- 18 Hawley SR, Paschal AM, Ablah E. et al. Initial perspectives from Midwestern neurologists: epilepsy patients' barriers and motivators for seeking treatment. Epilepsia 48 2007; 1920-1925
- 19 Huberty TJ, Austin JK, Harezlak J, Dunn DW, Ambrosius WT. Informant agreement in behavior ratings for children with epilepsy. Epilepsy Behav 1 2000; 427-435
- 20 Long L, Reeves AL, Moore JL, Roach J, Pickering CT. An assessment of epilepsy patients' knowledge of their disorder. Epilepsia 41 2000; 727-731
- 21 Dawkins JL, Crawford PM, Stammers TG. Epilepsy: a general practice study of knowledge and attitudes among sufferers and non-sufferers. Br J Gen Pract 43 1993; 453-457
- 22 Ried S, Specht U, Thorbecke R, Goecke K, Wohlfarth R. MOSES: an educational program for patients with epilepsy and their relatives. Epilepsia 3 2001; 76-80
- 23 Tran DS, Odermatt P, Singphuoangphet S. et al. Epilepsy in Laos: knowledge, attitudes, and practices in the community. Epilepsy Behav 10 2007; 565-570
- 24 Jarvie S, Espie CA, Brodie MJ. The development of a questionnaire to assess knowledge of epilepsy: general knowledge of epilepsy. Seizure 2 1993; 179-185
- 25 Goldstein LH, Minchin L, Stubbs P, Fenwick PB. Are what people know about their epilepsy and what they want from an epilepsy service related?. Seizure 6 1997; 435-442
- 26 Sidig A, Ibrahim G, Hussein A. et al. A study of knowledge, attitude, practice towards epilepsy among relative of epileptic patients in Khartoum State. Sudan J Public Health 4 2009; 393-398
- 27 Radhakrishnan K, Pandian JD, Santhoshkumar T. et al. Prevalence, knowledge, attitude, and practice of epilepsy in Kerala, south India. Epilepsia 41 2000; 1027-1035
- 28 Babikar HE, Abbas IM. Knowledge, practice and attitude toward epilepsy among primary and secondary school teachers in south Gezira locality, Gezira State, Sudan. J Family Community Med 18 2011; 17-21
- 29 Noronha AL, Andrade MG, Fernandes PT, Santiago SM, Sander SW. Training medical students to improve the management of people with epilepsy. Arq Neuropsiquiatr 65 2007; 23-27
- 30 Gedefa M, Wolde T, Solomon G. Knowledge, attitudes and practices with respect to epilepsy among Preparatory School Students in Mekelle city, Ethiopia. Int J Collab Res Intern Med Public Health 4 2012; 203-215
- 31 Joshi HS, Mahmood SE, Bamel A, Agarwal AK, Shaifali I. Perception of epilepsy among the urban secondary school children of Bareilly district. Ann Indian Acad Neurol 15 2012; 125-127
- 32 Shah AP, Parmar SA, Ramkishan A, Mehta AA. Knowledge, attitude and practice (KAP) survey regarding the safe use of medicines in rural area of Gujarat. Adv Trop Med Pub Health Int 1 2011; 66-70
- 33 McCluggage J, Ramsey HC, Irwin WG, Dowds MF. Anticonvulsant therapy in a general practice in Northern Ireland. J R Coll Gen Pract 34 1984; 24-31
- 34 Dowds N, McCluggage J, Nelson J. A Survey of the Socio-medical Aspects of Epilepsy in a General Practice Population in Northern Ireland. 1983. British Epilepsy Association Publications; London:
- 35 Hirfanoglu T, Serdaroglu A, Cansu A, Soysal S, Derle E, Gucuyener K. Do knowledge of, perception of, and attitudes toward epilepsy affect the quality of life of Turkish children with epilepsy and their parents?. Epilepsy Behav 14 2009; 71-77
- 36 Frank-Briggs AI, Alikor EA. Knowledge and attitudes of parents towards children with epilepsy. Ann Afr Med 10 2011; 238-242
- 37 Deng CT, Med M, Zulkifli HI, Azizi BHO. Parental reactions to febrile seizures in Malaysian children. Med J Malaysia 51 1994; 462-468
- 38 Modi AC, Rausch JR, Glauser TA. Patterns of nonadherence to antiepileptic drug therapy in children with newly diagnosed epilepsy. JAMA 305 2011; 1669-1676
- 39 Bobrow ES, AvRuskin TW, Siller J. Mother-daughter interaction and adherence to diabetes regimens. Diabetes Care 8 1985; 146-151
- 40 Patterson Jm. Critical factors affecting family compliance with home treatment for children with cystic fibrosis. Fam Relat 34 1985; 79-89
- 41 Davis KL, Candrilli SD, Edin HM. Prevalence and cost of non adherence with antiepileptic drugs in an adult managed care population. Epilepsia 49 2008; 446-454
- 42 Ettinger AB, Baker GA. Best clinical and research practice in epilepsy of older people: focus on antiepileptic drug adherence. Epilepsy Behav 15 2009; 60-63
- 43 Eisler J, Mattson RH. Compliance in anticonvulsant drug therapy. Epilepsia 16 1975; 203-206
- 44 Faught E, Duh MS, Weiner JR, Guerin A, Cunnington MC. Nonadherence to antiepileptic drugs and increased mortality: findings from the ransom study. Neurology 71 2008; 1572-1578
- 45 Nakhutina L, Gonzalez JS, Margolis SA, Spada A, Grant A. Adherence to antiepileptic drugs and beliefs about medication among predominantly ethnic minority patients with epilepsy. Epilepsy Behav 22 2011; 584-586